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New COVID19 Approved Office and Clinic Considerations

These policies were adapted from The Academy of Otolaryngology Head and Neck Surgery Guidelines.

Patient Encounters

• Pre-screening will be considered at the time of booking the appointment, prior to entry into the clinic, as well as at the start of the visit.

Important screening questions include exposure to contacts with COVID-19 infection, cough, shortness of breath, fever, chills with/without shaking, muscle pain, headache, and new loss of taste or smell (i.e., less than 14 days).

Patients who fail screening should be considered for more detailed screening or be evaluated via a telemedicine visit.

If there is concern about current COVID-19 infection, these patients will also be considered for testing and/or referred to their primary care physician or an appropriate COVID-19 testing facility.

• History taking will be performed if possible prior to the visit via phone, web portal, or telehealth in order to minimize the time the patient spends in the office and appropriately triage the patient.

• Patients will be informed at the time of scheduling to self-quarantine as much as possible prior to the appointment and to cancel in-office appointments if patients develop fever, cough, shortness of breath or difficulty breathing, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of smell/taste.

• The patient check-in process will screen them for COVID-19 symptoms and temperatures and/or pulse oximetry will be obtained.

• Our office is limiting individuals accompanying the patient to only those needed to directly support the patient (e.g., caregiver, parent of a minor, case manager, interpreter if telephone services are not available).

• All patients, including children, will wear a mask that covers the nose and mouth and be informed that it is to be worn at all times.

• All patients should maintain appropriate social distancing requirements in the waiting area after patient check-in.

• We will try to establish an appropriate number of patients scheduled per hour to allow for the increased time of check-in, patient encounter, room cleaning, and turn over.

• Our patients will wait in their cars and be called directly into the clinic room, with check-in performed in the clinic rooms.

• Our patients will be moved along designated paths to minimize contact among patients.

Our Staff Responsibilities

• All staff will be screened for COVID-19 symptoms and undergo temperature checks on a routine basis. These checks will be logged in the employee binder.

• All staff will practice social distancing and wear a mask at all times while in the work environment.

• All staff will adhere to recommended hand hygiene protocols (e.g., washing with soap and water for 20 seconds and using hand sanitizer).

• All staff will keep personal workspaces cleaned according to approved disinfectant protocols and store personal effects in appropriate places.

• Staff will wear appropriate PPE during patient interactions.

• Providers will wear appropriate PPE during patient encounters.

• All staff are proactively informed that they should not come to work prior to contacting their supervisor if they have any fever, new cough, new muscle aches, new shortness of breath, or new loss of sense of smell or taste.

Clinical Space Considerations

• The number of patients in the waiting room will be monitored to ensure that social distancing can be practiced.

• Exam room and nursing station counters will be cleared of excess paper products, supplies, and equipment. The number of items on counters should be a bare minimum.

• Office equipment, such as video towers, will be covered when not in use.

• We will monitor our PPE and cleaning supply inventory weekly and have a procurement plan.

• Inline filters are checked and changed regularly for the suction devices.

• We will maximize hand sanitizer visibility and access if available. If hand sanitizer is not available, we will encourage hand washing for staff and patients.

• We will eliminate magazines, brochures, pens, clipboards, and other loose materials and shared-use items from the waiting and exam rooms. All materials used during a patient encounter will be thoroughly sanitized using approved procedures prior to additional patient exposure.

Exam Room Considerations

• Staff will be trained and monitored to ensure the rooms are being cleaned and properly sanitized.

• Equipment and room cleaning protocols will be followed.

• Individual treatment trays will be used to avoid opening drawers. Once the doctor is in the room the MA is the only person to open and close the drawers while the patient is in the room.

• Dedicated medical equipment will be used when caring for patients with known or suspected COVID-19.

• Only essential staff and personnel will be in the exam room during all office procedures.

• If a confirmed COVID-19 positive patient is seen in the office and has an aerosol generating event, the exam room will be rested for an hour. (This number is determined by air exchange and other local factors).

Office Procedure Considerations

• Due to known limitations of available PPE, clinicians may have to reuse N95 masks or periodically decontaminate their PPE based on local policies, resources, and equipment.

• Designate a single room, microscope, and audiology booth for COVID-19 positive patients and persons under investigation and use an approved cleaning protocol after each use. 8

• We will limit atomizer and nebulizer use as much as possible. We will consider nasal pledgets or cotton soaked pledgets when decongestant or local anesthesia are utilized.

• We will have our patients wear masks, if possible, during office endoscopy.

• Laryngoscopy, nasopharyngoscopy, nasal endoscopy, manipulation of the external auditory canal, and other instrumentation of the upper airway will be carefully considered, as these are potentially AGPs if they result in a patient sneezing or coughing.

• If diagnostic endoscopy is necessary in a non-Covid-19 positive patient, PPE including exam gloves, a surgical mask (an N95 respirator is preferred if available), with a face shield or goggles if possible.

This recommendation can be adjusted based on availability and quality of COVID-19 testing and/or current local incidence of COVID-19.

• If available, a video system rather than direct visualization through the endoscope will be considered to keep the examiners face further away from the patient.

• Ear canal and mastoid instrumentation can elicit coughing due to stimulation of Arnold’s nerve cough reflex with resultant aerosolization. It is also theoretically possible that aerosolization could occur through instrumentation of infected tissue, including suction of middle ear effusions.

• Suction systems will be evaluated, and inline filtration is utilized when feasible.

• Suction tubing will be changed or sanitized per appropriate protocols after any encounter with a high-risk patient.

• Office procedures will be performed with as few staff present as possible.

• Proper protocols and precautions will be used for handling and cleaning instrumentation after the procedure.

Telemedicine

• Due to known limitations of available PPE, clinicians may have to reuse N95 masks or periodically decontaminate their PPE based on local policies, resources, and equipment.

• Designate a single room, microscope, and audiology booth for COVID-19 positive patients and persons under investigation and use an approved cleaning protocol after each use. 8

• We will limit atomizer and nebulizer use as much as possible. We will consider nasal pledgets or cotton soaked pledgets when decongestant or local anesthesia are utilized.

• We will have our patients wear masks, if possible, during office endoscopy.

• Laryngoscopy, nasopharyngoscopy, nasal endoscopy, manipulation of the external auditory canal, and other instrumentation of the upper airway will be carefully considered, as these are potentially AGPs if they result in a patient sneezing or coughing.

• If diagnostic endoscopy is necessary in a non-Covid-19 positive patient, PPE including exam gloves, a surgical mask (an N95 respirator is preferred if available), with a face shield or goggles if possible.

This recommendation can be adjusted based on availability and quality of COVID-19 testing and/or current local incidence of COVID-19.

• If available, a video system rather than direct visualization through the endoscope will be considered to keep the examiners face further away from the patient.

• Ear canal and mastoid instrumentation can elicit coughing due to stimulation of Arnold’s nerve cough reflex with resultant aerosolization. It is also theoretically possible that aerosolization could occur through instrumentation of infected tissue, including suction of middle ear effusions.

• Suction systems will be evaluated, and inline filtration is utilized when feasible.

• Suction tubing will be changed or sanitized per appropriate protocols after any encounter with a high-risk patient.

• Office procedures will be performed with as few staff present as possible.

• Proper protocols and precautions will be used for handling and cleaning instrumentation after the procedure.

• If possible and appropriate, the operating rooms will be designated for COVID-19 positive and COVID-19 negative patients.

• Intubation and AGPs should be performed in a negative pressure room with the door closed, if possible.

• All providers not essential for intubation should remain outside the operating room during endotracheal intubation and extubation to minimize exposure.

• In high-risk patients, procedures may be carried out by the most experienced surgeons to mitigate risk to staff and ensure minimal OR time. Trainees participation will be guided by local policies. Videotaping procedures with appropriate permissions may be used for teaching purposes outside the operating room.

• Proper PPE for the level of risk should be worn.

• When possible, attempts will be made to reduce particle distribution radius with surgical field coverage (e.g., draping), air evacuation (e.g., suction), and limiting the use of technology that theoretically may cause aerosolization.

• Modification of visualization techniques (e.g. surgical loupes, endoscopes in lieu of microscopes, etc.) may be necessary to accommodate different types of PPE.

• A barrier/drape will be placed between the surgical field and anesthesia.

• Given the possibility that aerosolization of viable pathogens (including virus) may also occur during electrocautery and generation of surgical smoke, consideration will be given to using additional local vasoconstriction and cold techniques during soft tissue dissection.

Specific Medication Concerns

Corticosteroid medications are frequently used in the treatment of various otolaryngologic disorders.

• Current recommendations advocate for continued use of inhaled steroids and nasal steroid sprays to maintain a healthy airway and avoid need for emergency care.

Systemic corticosteroids have special consideration in the era of COVID-19 infection. The use of systemic corticosteroids in patients with active COVID-19 infections have been shown to worsen infection in the early phases and should be avoided except in cases of ARDS. Corticosteroids are helpful for severe exacerbations of allergic diseases and asthma, often precluding the need for emergency care and can still be used in the COVID-19 era.

The decision for use of short bursts of systemic corticosteroids should be made with a shared-decision model, informing patients of the risks of potential worsening COVID-19 infection while helping them avoid emergent care where there could be exposure to COVID-19 positive.